Chapter One

american military medicine faces west

On June 13, 1900, Captain S. Chase de Krafft, m.d., a volunteer as-sistant surgeon with the American forces in the Philippines, reported from his post at Balayan the death from ‘‘hemoglobinuric fever’’ of Private

Glenn V. Parke of the 28th Regiment. In January, Parke had fallen out of

a march ‘‘from physical exhaustion’’ and was sent to the hospital in Ma-

nila. When he rejoined his company a few months later he appeared to be

well but soon succumbed to ‘‘malarial fever intermittent.’’ On the long, hot

march to Balayan, Parke had fallen out again and was admitted to the post

hospital with an acute attack of diarrhea. After daily doses of quinine and

thrice-daily strychnine, the soldier soon returned to duty. But his malarial

fever recurred: back in hospital he was ‘‘seized with a severe attack of bili-

ous vomiting,’’ and later his urine was red and scanty. The bilious vomit-

ing, diarrhea, and fever persisted, along with pain over the liver; his entire

body was soon ‘‘saffron-colored.’’ His urine became darker and more con-

centrated. Within a few hours, the patient sank into delirium and then coma,

dying early in the morning. Parke had told the surgeon he was twenty-three

years old, though most suspected he was no more than twenty-one; in any

case, his body was quickly buried in the north side of the cemetery at Balayan.

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14 american military medicine faces west

De Krafft then turned his attention to ensuring the well-being of the re-

maining troops.∞

Tropical disease would take the lives of many U.S. soldiers during the

Philippine-American War. From General Wesley Merritt’s assault on Manila

on July 31, 1898, until the war gradually eased in 1900, more than six hun-

dred soldiers were killed or died from wounds received in battle, and another

seven hundred died of disease.≤ The record of Parke’s clinical course presents

in unusual detail an example of diagnosis and treatment in the medical corps

of the U.S. Army during the first year of the campaign. The army surgeon in

the field was still likely to attribute illness to exhaustion or reckless behavior

and to favor explanations that implied a mismatch between bodily constitu-

tion and circumstance. In his extensive case notes, de Krafft nowhere men-

tions germs, even though the microbial causes of diarrhea and malaria had

been established for many years. Parke’s feces were not cultured for bacteria;

his blood was not examined for the malaria parasite. Instead, the surgeon

carefully described the vitality and appearance of the patient, the strength of

his pulse, the qualities of his dejecta, and the hourly variations in body tem-

perature. The diagnosis was expressed not in terms of any causative organism

but as a type of fever, a bodily response not identified with any inciting agent.

In a tropical environment, in conditions that supposedly depleted white con-

stitutions, the surgeon turned naturally to stimulants—strychnine, quinine,

mustard plasters, and eggnog—to rally Parke’s resisting powers.≥ There was

no suggestion that a medication might attack directly a microbe or other

specific cause. The surgeon hoped to restore his patient’s balance and vitality

and thus combat the nonspecific challenges of overwork or feckless behavior

in trying foreign circumstances.

The surgeon’s meticulous attention to this individual case reveals more

than just the expediency and deftness required in clinical engagement under

such grueling conditions. It also indicates medical priorities in the U.S. mili-

tary at the outset of the war. In an elaborate epidemiological reconstruction of

the effects of the Philippine-American War on the local population, Ken de

Bevoise has estimated that the annual death rate in the archipelago, previ-

ously a high thirty per thousand, soared to more than sixty per thousand

between 1898 and 1902, and that more than seven hundred thousand Fili-

pinos died in the fighting or in concomitant epidemics of cholera, typhoid,

smallpox, tuberculosis, beriberi, and plague.∂ Displaced and destitute, some-

times crowded into reconcentration camps, ordinary Filipinos were especially

vulnerable to disease. Endemic infection, previously contained, flared into

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american military medicine faces west 15

epidemics; new diseases, some perhaps carried by invading troops, soon be-

came rife. But the spread of disease among local communities was not, in the

early stages of war at least, the main concern of the medical corps of an

attacking army.

The job of a military surgeon, recently codified in the U.S. Army, was

clearly delimited.∑ During battle, the care and evacuation of sick and wounded

soldiers would inevitably preoccupy the military surgeon; at other times, in

the respite from the demands of surgical treatment of acute cases, the surgeon

worked to ensure the sanitation of camps and the hygiene of troops. ‘‘A

military surgeon who believes he is appointed for the sole purpose of extract-

ing bullets and prescribing pills,’’ according to Captain Charles E. Woodruff,

m.d., was ‘‘a hundred years behind the times.’’∏ The medical officer was also a

sanitary inspector, responsible for the scrutiny of food, provision of adequate

clothing, ventilation of tents, disposal of wastes, and the general layout and

‘‘salubrity’’ of camps. In the past, according to Woodruff, the military sur-

geon might have restricted himself to preventing and eradicating ‘‘hospital

contagion’’—gangrene among the wounded and fever (usually typhus) among

long-term inmates—but now, in the ‘‘modern era,’’ he had a duty to provide

for the well-being of troops. Thus de Krafft, after hastening the disposal of

Parke’s body, had gone about trying to prevent other cases. ‘‘The army medical

officer,’’ noted a contemporary observer, ‘‘ceased to be primarily a general

practitioner in becoming the administrative officer of a sanitary bureau, with

certain clinical duties when accident or the failure of prevention placed the

individual soldier for special care in a hospital ward.’’π

In seeking to protect white soldiers, the military surgeon in the Philippine-

American War repeatedly assayed the nature of the territory and climate and

the character and behavior of troops and local inhabitants. Like medicine

more generally, army sanitary science was heedful of environment, social life,

and morality; always conservative, it tried to guard against any radical depar-

ture from the body’s accustomed locale and mode of existence. Alterations in

living conditions, in patterns of human contact, and in exposure to different

climates might exert a direct impact on the soldier’s body and temperament,

or they might imply some perilous modification of his microbial circum-

stances. For troops like Parke, going to the tropics to fight a war meant

encountering a peculiar new physical environment and exotic disease ecology.

The conditions would be incongruent with those that whites experienced

in most of the United States, and therefore potentially harmful in ways as

yet undetermined. To predict and stave off disease, the medical officer had

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16 american military medicine faces west

figure 1. U.S. troops on the road to Malalos, 1899 (rg 165-pw-81608, nara).

to understand the effect of an alteration in circumstances or habits on his

charges and learn how to mitigate or combat the pathological concomitants

of change and mobility. To stay healthy the soldier must either reassert his

previous pattern of life or establish a different means of coping with the novel

environment and deployment. Military medicine in the Philippines thus was

predicated on appraisal of territory, climate, and behavior; it sought con-

stantly to protect the vulnerable alien race from strange circumstances and

dangerous habits and to teach presumably transgressive soldiers how they

might inhabit a new place with propriety and in safety.

Most of the troops in the Philippines would describe themselves as white—

the term crops up repeatedly in letters and reports—so it is tempting to regard

military medicine, at least in part, as an effort to gauge white vulnerability

and to strengthen white masculinity in trying foreign circumstances.∫ Indeed,

it often proves difficult to extricate concerns about the character of whiteness

from fears of disease in the tropics. Would the white race degenerate and die

off in a climate unnatural to it? Would the discord of race and place produce a

deterioration of white physique and mentality that shaded into disease? Were

the tropics inimical to the white man? Such questions still puzzled medical

officers and soldiers alike. Most of the time, of course, military surgeons like

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american military medicine faces west 17

de Krafft were preoccupied with alleviating disease and treating injuries. But

sanitary duties ensured that medical officers would also strive to restructure

and secure the boundaries of white masculinity in the colonial tropics, to

determine how to preserve Anglo-Saxon virility and morality in a hostile

region, a place bristling with physical, microbial, and native foes. As so often

in the past century, the U.S. Army provided a model, an ideal space, for

working out political and social problems that also beset the unruly public

sphere—whether in the metropole or the colony. Thus the care and disciplin-

ing of white troops would come to serve as a test case for how to manage

white American colonial emissaries and later as a guide to how natives might

be reformed into self-disciplined ‘‘nationals.’’Ω In order to understand these

subsequent transfers and substitutions it is necessary to take a closer look at

the fighting white man and his tropical burden.

to the philippines

Admiral George Dewey’s victory over the Spanish fleet in Manila Bay on

May 1, 1898—one of the early engagements of the Spanish-American War—

signaled the entry of a new colonial power into Southeast Asia. President

William McKinley hurriedly arranged to send a military expedition, assembled

mostly in the western states, to take possession of the Philippines. But by the

time the U.S. Army arrived later in 1898, Spanish authority had collapsed, and

Emilio Aguinaldo’s rebel forces had taken control of most of the provinces.

The commander of the Spanish garrison in Manila surrendered to the expedi-

tionary forces, and so Filipino troops, spurned as allies, decided to entrench

themselves around the city. In the Treaty of Paris, signed on December 10,

1898, Spain disregarded Filipino nationalist aspirations and formally awarded

the United States sovereignty of the archipelago. During the next four years,

American forces engaged in a bitter and brutal campaign against the Philippine

insurrectos in order to secure the new possessions.∞≠ The logic of westward

expansion was to leave the United States with a Southeast Asian empire, one

that would last another forty or so years. In supplanting Spain, America thus

unexpectedly took its place in the region alongside the Dutch in the East Indies,

the British in Malaya and Hong Kong, and the French in Indochina. But for

U.S. colonialists, these older European imperial entanglements would more

commonly constitute object lessons than models worth emulating.

The troops had arrived in an archipelago of over seven thousand islands,

supporting a population of close to seven million people, most on the island

of Luzon. With a mean annual temperature of eighty degrees Fahrenheit, an

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18 american military medicine faces west

average humidity of 79 percent, and distinct wet and dry seasons, the climate

of Manila assuredly is tropical, however one might imagine that indefinite

quality. The rainy season lasts from June through November, after which the

weather can be quite pleasant, tempered by sea breezes. Although Manila’s

average temperature may be a little higher and its humidity a little less, it

seemed to many Americans that the weather there might be similar to condi-

tions prevailing in Rangoon, Bombay, and Calcutta.∞∞ It was in any case a

climate few Americans had experienced.

As Benedict Anderson has remarked, ‘‘Few countries give the observer a

deeper feeling of historical vertigo than the Philippines.’’∞≤ In the late six-

teenth century, the Spanish had occupied Luzon and made Manila their capi-

tal. After three hundred years of Spanish clerical colonialism, fewer than 10

percent of the local inhabitants were literate in Spanish, yet some of the

Catholic religious orders—the Jesuits and Dominicans especially—had sup-

ported pioneering natural history and astronomical research, and from the

seventeenth century had even sponsored universities in the archipelago. Thus

José Rizal, novelist, physician, and nationalist, in the 1880s reflected that ‘‘the

Jesuits, who are backward in Europe, viewed from here, represent Progress;

the Philippines owes to them their nascent education, and to them the Natural

Sciences, the soul of the nineteenth century.’’ Various religious orders had

established hospitals for the poor, and colleges for the small mestizo and

criollo elite. The San Francisco Corporation founded the San Lazaro Hospital

in 1578, initially for the poor in general but after 1631 reserved for the

increasing number of lepers. In Manila, the Hospital de San Juan de Dios, for

the care of poor Spaniards, opened in 1596; and the Hospital de San José was

established in Cavite in 1641. The University of Santo Tomás, which the

Dominicans founded in 1611, belatedly allowed the organization of faculties

of medicine and pharmacy in 1871. Scientific and medical journals soon

proliferated: the Boletín de medicina de Manila (1886), the Revista farma-

céutica de Filipinas (1893), the Crónicas de ciencias médicas (1895), and

others. Provincial medical officers, the médicos titulares, were first appointed

in 1876; and the Board of Health and Charity, equivalent to a public health

department, was established in 1883 and expanded in 1886. Sanitary condi-

tions in the capital were changing during this period. The government put

sewers underground in Manila during the 1850s; in 1884, the Carriedo wa-

terworks opened, giving the city the purest water in Southeast Asia.∞≥ The

central board of vaccination had been producing and distributing lymph since

1806; by 1898 there were 122 regular vaccinators—notoriously inept and

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american military medicine faces west 19

figure 2. Manila street scene, Binondo 1899 (rg 165-pw-35-9, nara).

lazy—passing the time in Manila and the major towns.∞∂ In 1887, the Spanish

colonial authorities set up the Laboratorio Municipal de Manila to examine

food, water, and clinical samples—but evidently it was rarely used.∞∑ None-

theless, it is clear that recognizably modern structures of public health and

medical care were taking shape in Manila and its immediate hinterland.

The 1870s had witnessed vast improvements in communication with Eu-

rope and an expansion of traffic between metropole and colony. From 1868,

vessels could use the Suez Canal, reducing the journey between Europe and

the Philippines from four months to one month by steamer. In 1880, cable

linked Manila more closely to Europe than ever before. Better connections

with Spain reduced the influence of foreign traders in Manila and encouraged

Spaniards to move to the islands. In 1810, there had been fewer than four

thousand peninsulares and Spanish mestizos in the archipelago, mostly clus-

tered in Manila (compared to several million indios throughout the archipel-

ago); in 1876, four thousand peninsulares and more than ten thousand mes-

tizos and criollos lived in the Philippines; by 1898 the numbers had swelled to

more than thirty-four thousand Spaniards, including six thousand govern-

ment officials, four thousand army and navy personnel, and seventeen hun-

dred clerics.∞∏

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20 american military medicine faces west

As they increasingly became committed to nationalism, science, anticleri-

calism, and political reform, a growing number of mestizos and criollos in the

archipelago began to call themselves Filipinos and to represent themselves as

ilustrados, or enlightened reformers.∞π In part, the progressive sentiment, ex-

pressed first in the Propaganda movement, derived from Spanish liberal and

secular agitation, which had culminated in the revolution of 1868—just as

the conservative reaction in Spain was echoed in the Philippines after the

1872 Cavite rebellion. But local factors also contributed. The school reforms

of 1863 had established a framework, still grossly inadequate, for a state

system of primary education. Improved commercial opportunities allowed

the expansion of the middle class; ambitious and progressive Filipinos began

sending their sons to France and Spain for higher education; talented local

candidates resented the peninsulares, who took most of the top government

posts; and more efficient communication helped to break down regional sepa-

ratism and conflict in the islands. Furthermore, racial distinctions became

especially marked toward the end of the century, and there emerged ‘‘a ten-

dency to thrust the native aristocracy into a secondary place, to compel them

to recognize ‘white superiority,’ to a degree not so noticeable in the earlier

years of Spanish rule.’’∞∫ Initially, local ambitions and resentments found

expression in moderate groups such as Rizal’s Liga Filipina. But in 1892,

Andrés Bonifacio organized the Katipunan, an anticlerical and anti-Spanish

brotherhood that in 1896 led an insurrection against Spanish control. The

friars attributed disaffection to ‘‘Franc-Masonería,’’ for them the epitome of

everything pernicious in modern life; and the Spanish army attempted to

suppress the rebellion, employing such brutality that even moderates turned

against Spanish rule.∞Ω But by the time Aguinaldo was able to declare the

Philippine Republic in 1899, the United States had claimed the archipelago.

José Rizal, the so-called First Filipino, was one of the leaders of the rising

generation of nationalists. From the Jesuits at the Ateneo de Manila Rizal had

received a solid grounding in the sciences, even if he subsequently argued that

Jesuit education had seemed progressive only because the rest of the Philip-

pines was mired in medievalism. But at Santo Tomás, studying science, he

found that the walls ‘‘were entirely bare; not a sketch, nor an engraving, nor

even a diagram of an instrument of physics.’’ A mysterious cabinet contained

some modern equipment, but the Dominicans made sure that Filipinos ad-

mired it from afar. The friars would point to this cabinet, according to Rizal,

to exonerate themselves and to claim that it was really ‘‘on account of the

apathy, laziness, limited capacity of the natives, or some other ethnological or

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american military medicine faces west 21

figure 3. Interior of the Spanish Bilibid Hospital. Courtesy of the Rockefeller Archive Center.

supernatural cause [that] until now no Lavoisier, Secchi, nor Tyndall has

appeared, even in miniature, in this Malay-Filipino race!’’≤≠ (Still, it should be

recalled that nowhere else in Southeast Asia was education available at such

an advanced level.)≤∞ In 1882, Rizal traveled to Spain to study medicine, and

he later visited France and Germany. He was astonished and embarrassed by

the political and scientific backwardness of the imperial power. In Europe,

medicine, political activism, and the writing of his brilliantly sardonic novels

occupied most of his time, but after Rizal returned to the Philippines and was

confined at Dapitan, he also began collecting plants and animals and discov-

ered new species of shells.≤≤ During this period, Rizal engaged in a copious,

self-consciously enlightened correspondence with Ferdinand Blumentritt, the

Austrian ethnologist, and translated into Spanish many of his works on the

Philippines.≤≥ For Rizal, a commitment to science and reason informed patri-

otism, and patriotism implied a scientific orientation to the world. Unim-

pressed, the clerical-colonial authorities executed the First Filipino in 1896.

Rizal did not live to see the United States completing the work of Spain and

crushing the nationalist forces. The Philippine-American War would directly

and indirectly cause widespread sickness, injury, and suffering as well as

destroy much of the recently constructed apparatus of education and public

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22 american military medicine faces west

health in the archipelago. The nascent, weak public health system broke

down completely, the Filipino sick and wounded overwhelmed local hospi-

tals, vaccination ceased altogether, and colleges and universities either closed

or struggled to graduate students. Thus as Americans assumed control they

found little evidence of previous scientific and medical endeavor and felt

justified in representing the Spanish period as a time of unrelieved apathy,

ignorance, and superstition, in contrast to their own self-proclaimed moder-

nity, progressivism, and scientific zeal.

the army medical department

When John Shaw Billings addressed the graduating class of the Army Medical

School in 1903, he celebrated the great progress in military medicine he had

observed over the past fifty years. Billings recollected that the president of the

Army Medical Board who examined him in 1861 had been inclined to remi-

nisce along the same lines, praising the recent introduction of anesthesia and

the new operations for excision of joints. The examining surgeon in those

days had heard of the clinical thermometer and the hypodermic syringe but

doubted that either would prove useful. The young physician, soon to join the

Army of the Potomac, was asked to describe ‘‘laudable pus’’ and the best

means of securing healing by second intention. He was questioned on the

means of preventing malaria and typhoid fever among troops. ‘‘If I had re-

ferred to bacilli, hematozoa, flies and mosquitoes, as you would probably do,

I don’t think I should have passed.’’ Just as the symbol of the old military

surgeon was the scalpel, his new emblem ought to be the microscope. ‘‘Forty

years ago the microscope was mainly used by physicians as a plaything, a

source of occasional amusement,’’ Billings recalled. ‘‘Today the microscope is

one of our most important tools.’’≤∂ Although the bookish sanitarian was

perhaps overestimating the bacteriological grasp of most military surgeons

and ignoring the difficulties of using the new techniques in the field, it was

true that during the previous forty years the role of the army medical officer

had changed beyond recognition.

The intellectual and professional transformation of military medicine en-

compassed both its therapeutic and its prophylactic aspects. The new medical

officer combined clinical duties with administrative tasks designed to prevent

disease outbreaks, or at least to provide early warning of them. Of course, in

times of war it was still the care of the sick and wounded that took most of the

time and energy of the military surgeon. Since the Civil War, changes in the

combat zone and in medical technology had transformed the scope and char-

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american military medicine faces west 23

acter of these clinical duties. By the 1890s, antiseptic methods prevailed in

the operating room, primary union could be secured in gunshot wounds,

depressed skull fractures were operable, and wounds of the intestine, once

considered beyond surgical relief, on occasion were sutured in risky laparoto-

mies. The military surgeon was more confident and optimistic than ever be-

fore in his ability to intervene clinically. General George M. Sternberg, m.d.,

the surgeon general of the army and the president of the Association of Mili-

tary Surgeons, in 1895 observed that his colleagues, as a consequence of these

advances, would have ‘‘to devote much more time to individual cases than

was thought necessary during our last war.’’≤∑ The army needed more medical

staff, with better training, and it needed more ambulance officers and sanitary

assistants to take on the first-aid work. The trained surgeon could then move

from the firing line, where staunching hemorrhage was the most that could be

done, to the new field hospital, where he now might operate.≤∏

If all had gone well, by the time the wounded soldier arrived at a distant

field hospital, an elastic bandage (or, more likely, the old-fashioned tourni-

quet) would have been applied on the firing line to stop any hemorrhage, and

at the dressing stations bleeding vessels tied with ligatures of catgut or silk and

wounds plugged with gauze.≤π In the field hospital, the patient might receive

opium to relieve pain and to prevent the ‘‘depression of shock,’’ though some

medical officers preferred to administer alcohol by mouth, enema, or hypo-

dermic injection, on occasion combining it with nitroglycerine. At the hos-

pital, surgeons took special care to remove any foreign bodies, any contami-

nants, and they would enlarge the wound if necessary. ‘‘One speck of filth, one

shred of clothing, one strip of filthy integument left in ever so small a wound

will do more harm, more seriously endanger life, and much longer invalid the

patient, than a wound half a yard long in the soft parts, when it is kept

aseptic,’’ warned one military sugeon.≤∫ If the campaign had been long and

severe, with the soldiers hard-pressed and huddled together without bathing

facilities or changes of clothing, ‘‘they are quite apt to get into a horrible

condition of filth and the presumption will be in favor of every wound being

infected and apt to do badly.’’≤Ω In such conditions, conservative treatment

was often fatal, and any attempt at asepsis would be better than none.

Of course strict asepsis was usually impossible in the field. And even when

antiseptics were available, it was sometimes hard to find the large quantities

of pure water required to dilute them. ‘‘You can imagine our horror,’’ a

surgeon recalled, ‘‘to find ourselves in the midst of a dozen or two operations

with dirty, bloody hands and instruments, blood, vomited matter and other

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24 american military medicine faces west

filth strewn on the ground, and no water to clean up.’’≥≠ Nor was it easy to

keep boiling water clean on an open campfire: the smoke would rise and

spread dirt and soot on it. Operations in the open and even in tents would

quickly be covered in dust if the wind rose, often making even ‘‘the antiseptic

lotions look like mud.’’≥∞ The exigencies of battle left no …

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